Focusing on the Patient Journey in Specialty Pharmacy is Essential

In an interview with Pharmacy Times, Denise Scarpelli, PharmD, MBA, vice president and chief pharmacy officer at the University of Chicago, discussed her presentation at the American Society of Health-System Pharmacists (ASHP) 2023 Summer Meeting. Scarpelli’s session discussed the current state of specialty pharmacy and the importance of focusing on the patient journey.

Q: Why is the focus on the patient journey in specialty pharmacy so important?

Denise Scarpelli, PharmD, MBA: It's important because I think a lot of specialty patients don't realize the journey that they are going to start once they're diagnosed with something that requires a specialty medication. It's not your traditional pharmacy medication that you would get at a retail pharmacy. And I think some of patients don't realize the cost of these drugs; they require prior authorization. Sometimes pharmacies are limited to access to these, the plan that they're on may limit what pharmacy they can use. So, patients really need their hand held as they start this journey.

So, you know, health system pharmacists are equipped to do this, they're embedded in clinic, the providers can hand them right over to a pharmacist to help that patient with their journey, help them navigate their insurance, figure out what their copay is. If it's a pharmacy that the current health system pharmacy can't fill it, what pharmacy can and getting it to the right pharmacy for them, instead of that patient trying to figure that out, even if the health system can fill it. Usually these have very high copays and I think patients are shocked when they're hearing a copay of $1,000. They're used to their $5, $10, $20 copay and don’t realize there's a higher copay for this. The pharmacist can help find patient assistance programs or other avenues to help get that high copay covered. The pharmacist and a health system specialty pharmacy can also help if the patient needs certain labs before the drug is started, or maybe immunizations. So, pharmacists being embedded in clinic can really help that patient start that journey and help them through it and get them to the right pharmacy. And I think when a patient is just handed the script and the pharmacist or the provider says go to your pharmacy, a lot of times what happens is it doesn't get filled, the patient calls back, the provider has to get involved, and it could take longer for that patient to get on that drug.

Q: What does the patient journey tend to look like in specialty pharmacy?

Denise Scarpelli, PharmD, MBA: Yeah, you know, when the patient gets diagnosed with a disease state that requires a specialty medication, it comes as a shock. Sometimes they're still trying to comprehend what they're diagnosed with if it’s oncology or some sort of immunocompromised kind of condition that they're going to have to live their whole life with. And their life can change, so they're processing that. But then also realizing that these medications are very expensive, being able to find access, maybe that has a wide range of side effect profiles, maybe they're already on medications that interact with that. And so, I have to worry about the other drugs that I'm on. I think a lot of patients don't realize you can't get this at your regular retail pharmacy most of the time. Some of them you can; most of them you cannot. And depending on some of the drugs, you can only get maybe 1 or 2 pharmacies and trying to figure out where I can find these drugs. Having a pharmacist embedded in a health system specialty clinic, that pharmacist knows where those drugs are at. And especially in some of those clinics, they may be prescribed 6 or 7 different drugs, that pharmacist becomes an expert in those drugs, who has it, what copay assistance is out there, patient assistance programs—they know everything that patient needs to help them with the journey. So, they kind of take that burden off that patient and it really helps that patient, holds their hand as they start that.

Even as that patient continues on that treatment, you know, maybe the insurance changes a year from now, that pharmacist says, “Don't worry, I'll help you navigate that new insurance plan.” Maybe the treatment stops working and then you need to change therapies. Again, don't worry about it, I can help you navigate that new treatment. Even if the patient assistant program expired, because a lot of them require authorization every year, that pharmacist and health system pharmacy know when those authorizations are expiring and already begin that reauthorization so there's never a disruption in care for that patient. Maybe the patient loses their insurance and they're working with the provider, that pharmacist in that clinic can help with the gaps in therapy. Sometimes they have free drugs that they can work with.

But that pharmacist helps that patient through the entire journey from the start and is always there for them. Even if that specialty pharmacy is not filling the drug, their pharmacist is still embedded in clinic and becomes that vital resource for that patient to help them no matter what the issue is. But I think a lot of times when patients start on this, they have no idea where to begin. So, if you have a specialty clinic, the pharmacist is embedded in that clinic. A lot of times the provider or the nurse is trying to help navigate that patient, and a lot of times they don't have the expertise or the background of knowing all the different things that are out there for the patient. They do their best. But again, having that pharmacist that knows everything about the drug, all the patient assistance programs, and all the things or all the restrictions based on payers, and maybe access to that drug, it really helps ease that burden for the patient.

Q: Access is a key issue in specialty pharmacy. What are the obstacles in the way and how are these issues being addressed?

Denise Scarpelli, PharmD, MBA: So, 51% of the drugs on the market today are specialty, and all the ones that continue to come out are always specialty drugs. And a lot of these are orphan drugs, where, you know, it's a very small [patient] population. And so, when you talk about access to some drugs on the market, it's to pharmacies that get access to that drug. So really, you have to know who has it. Sometimes providers don't even have an idea of who has access to these drugs. But then it also comes from the patient's insurance. So, with insurance, you can have many different types of access, if it's an employer plan, if it's in a Medicare plan, there are different designs. And sometimes, you know, I could have a payer and you could have the same one, but our design is different when it comes to specialty. So, when the cost of health care is increasing, employers and payers are looking for ways to control that cost. So, a lot of times a patient doesn't know where they can go get these drugs, you can't walk into a Walgreens or CVS and hand them the script and say, “Can I get this today.” That's not going to happen. And, really, having a pharmacist embedded in that clinic can help their patient navigate where they can get this drug, maybe the health system pharmacy can fill it, if they can't, then they know who can fill it. And they'll do that soft transfer over to that other pharmacy that can fill it. Most health system pharmacies will already work on the patient assistance program, have everything already worked up and then hand it over to the pharmacy that can fill it and then they close the loop with the provider.

But again, that patient, if they didn't have that help in the specialty pharmacy, goes home. And the provider says, “Well, I'm going to send it to this specialty pharmacy and they'll be contacting you.” A lot of times that patient doesn't hear from that specialty pharmacy for days, and then trying to navigate those specialty pharmacies. Sometimes you're in this like black hole and you're calling from person to person. So, it's really that pharmacists will help that and a lot of specialty health system pharmacists have contacted each of these payers, they know who to call at that pharmacy to help navigate. But I think patients don't realize the difficulty until they start that journey. And if they don't have a health system pharmacist, and they're sent out and are trying to do this on their own, usually they're very frustrated. They want to get the drug and sometimes it could take weeks for them to be able to get it. So having that pharmacist embedded in clinic really helps them gain access faster. Or maybe it’s affordable. Maybe they found the pharmacy but then they get a $1,000 copay. I don't have $1,000, what do I do? So, it all depends on the help that pharmacist is going to provide them and having that pharmacist embedded in clinic builds that relationship with the patient. It's a trusted resource that's connected with their provider and instead of someone calling them on the phone and saying that I'm from the specialty pharmacy, we're going to help you. I think people don't realize how difficult it is to get access to a lot of these drugs. It could be limited pharmacy; it could be limited distribution. It could be narrow network, so a lot of different access issues that that patient will face as they started this journey.